Cognitive Behavioural Therapy (CBT) in North America

How do GPs in North America decide what type of psychotherapy to suggest? A Canadian GP describes how he decides.

Dr. Gerald van Gurp is a general practitioner/family physician in Montreal. He lectures in the Department of Family Medicine of McGill University. The author has no competing interests.

CBT is a practice which focuses on the current problems and difficulties in a client’s life; instead of focusing on the causes of distress or symptoms of the past, it is used to find ways to rapidly improve the state of mind in the present time. Using his knowledge from reading research from large electronically available databases, Gerald van Gurp discusses how he arrives at the conclusion that the use of CBT to address difficult mental problems in his patients is the best and most convincing choice of those that arise as a GP in Montreal, Quebec, Canada.

From the point of view of the family physician, of all the therapies available to treat mental health problems and physical conditions with an important psychological component, CBT appears to be the flavor of the month, the decade, and for decades to come. The reason for this is the rightful preoccupation that doctors have with evidence-based medicine (EBM). Before advocating any new treatment, be it psychological or chemical, North American GP’s and, to some extent, third party payers expect that a high standard of proof of effectiveness has been shown. Most of the time this means that at least one randomized controlled trial (RCT) has been published in a reputable, peer–reviewed journal. Increasingly, pooled data from several studies, all demonstrating methodological rigor, in the form of a systematic review or meta-analysis, is called for. The gold standard in this regard is the work done by the Cochrane Collaboration (www.cochrane.org) , which if not familiar to the reader, is a must-browse.

In most Canadian provinces and throughout the US, general practitioners are required to keep up-to-date with a requisite number of hours annually of continuing medical education. This may entail journal reading, attendance at approved courses or hospital-based conferences. What we have been hearing from all sources for several years is that when we encounter conditions that call for psychotherapy, CBT is the way to go. We are also urged to ascertain whether the colleagues to whom we refer are trained in CBT which, according to a recent survey, was only the case for 11% of therapists in Quebec.

Who should perform CBT? A small number of general practitioners/family doctors do so after having enrolled on courses with as little as six hours duration. A 2002 article in the British Medical Journal in which 84 North London GP’s became CBT therapists after only four and a half days training suggested that such preparation was inadequate. A more recent, less rigorous Canadian study suggested that even a six hour course was to some extent useful. Clearly the jury is still out on the question of how much training is required. It’s worth noting that in both studies, Mind over Mood by Greenberger (1995) was the training text that was used.

I took the initial step of purchasing this programmed text with its companion clinician’s guide and found it concise, clear and user-friendly. On the other hand, I have not taken the next logical step of enrolling in a training session. To be available for any course of between 6-24 weekly sessions is an obstacle for many clinicians, myself included.

The question arises: Why is CBT so highly recommended by pundits and opinion leaders of the medical community? The short answer is that according to the methods by which that community gauges effectiveness of treatments i.e. rigorous scientific evaluation, it appears to work.

In what follows I’ll share with you the current consensus of medical opinion on the role of CBT in the management of frequently seen psychiatric ailments as well as a few physical conditions, but before doing so, it would be useful to describe a randomized –controlled trial, the cornerstone of evidence-based medicine. An RCT in which I was involved in 2002 examined depressed patients visiting offices of general practitioners in Montreal. The main objective was to ascertain whether patients with major depression recruited from a primary care setting improved more during a three month treatment period with St John’s Wort or with the antidepressant sertraline (Zoloft). Half of the 87 participants received one of the treatments which were carefully masked to be indistinguishable to patients and doctors, and their allocation was random.

One such study may not be considered enough to justify a strong message to practicing clinicians. In fact at around the same time that our study was published, a larger, American trial in a tertiary care setting, involving patients who were more severely depressed, drew a conclusion different from our own. Hence we needed to look at the results of as many RCT’s as possible in the form of a systematic review or meta-analysis, the speciality of the Cochrane Collaboration. This has been done in the case of St. John’s Wort for depression.

The more psychotherapeutically minded GPs may carry out their own research of the appropriate treatments for patients presenting mental health problems. My own research (using the online libraries of RCT’s, systematic reviews of Cochrane, past issues of the very practical and much read American Family Physician and the data bank of the continuing medical education site, Info-POEMS [problem-oriented evidence that matters] and summarized the observations) found the evidence-base for effective use of CBT.

Entering the following keywords, ‘cognitive behavioral therapy’, psychological therapy(ies)’, as well as the names of a number of conditions themselves onto the online databases, the argument for the referral to CBT is strong. In the following list, I outline the evidence that I found for referring for CBT.

PTSD – A 2005 Cochrane review looked at 29 studies of psychological treatment of post-traumatic stress disorder. Trauma-focused CBT and stress management appeared to be effective as did eye movement desensitization and reprocessing. Other therapies (supportive, non-directive counselling, psychodynamic therapy and hypnotherapy) were found not to be superior to waitlist/usual care (the control group). In reference to ‘other therapies’, the review stated that there was evidence of a greater drop out rate in psychological treatment groups, unexplained heterogeneity observed in the comparisons it recommends caution in interpreting the results of the review.

Generalized anxiety disorder (GAD) – Twenty-five RCT’s with 1060 subjects contributed data to a systematic review concluding that CBT was more effective than treatment as usual/waitlist. A few of the studies compared CBT with supportive therapy but heterogeneity and small numbers precluded drawing any firm conclusions.

Panic Disorder – An article on the treatment of panic disorders in the American Family Physician (AFP) looked at multiple evidence-based reviews. Strong evidence supported the effectiveness of CBT alone or in combination with anti-depressants. At 3-4 months 73% of CBT treated- patients were panic-free compared to 27% of controls with 46% remaining symptom-free at two years. Longer-term studies suggested that CBT alone was better than anti-depressants which, when continued for more than six months did not reduce relapse rates.

Social Phobia – CBT lasting from 16-24 sessions, whether in individual or group format was found to be particularly effective for treating social phobia when compared to supportive care. Authors of a review in AFP also noted a lower relapse rate compared to treatment with anti-depressants after discontinuation of therapy. As in any condition in which pills and talking therapy both work, patients’ preferences are paramount.

Obsessive-compulsive disorder – A Cochrane review examined eleven studies comparing a control to cognitive behavioral therapy and concluded that any variant thereof was effective.

Adjustment reaction – No meta-analysis was found but one RCT compared problem-focused CBT with ‘supportive’ counseling for 57 patients with cancer and an abnormal adjustment reaction. The authors concluded that the CBT group had a greater improvement in anxiety, adjustment to cancer and use of coping strategies than patients receiving supportive counselling. The effects were measured after eight weeks of treatment and were still apparent at four months.

Major depression – Authors in AFP cite numerous RCT’s and meta-analyses showing CBT to effectively treat unipolar major depression, possibly more so in mild-to-moderate cases. They clarify additionally that it is as effective as interpersonal or a brief psychodynamic approach.

Depression in childhood and adolescence – Similar conclusions were drawn about childhood and adolescent depression: that CBT is the first choice in mild-to moderate cases and anti-depressants considered for patients with more severe disease.

Chronic fatigue syndrome (CFS) – According to a Cochrane review which included 164 subjects in three trials, the physical functioning of adults with severe CFS benefitted from CBT when compared to orthodox medical management or relaxation therapy. There was no statistical difference, however, for patients with milder forms of the condition typically seen by GP’s.

Fibromyalgia – A meta-analysis of studies looking at treatment for the fibromyalgia syndrome concluded that together with pills and exercise, CBT can play a useful therapeutic role.

Obesity – The obesity epidemic in North America should be attacked using an approach that includes stimulus control and cognitive re-structuring (under the rubric of CBT), and, according to authors of a systematic review in AFP, stress management and social support.

Eating Disorders – The same appears to apply to binge-eating and bulimia although much less successful in the case of anorexia nervosa.

The above list does not pretend to be a literature review, but rather intends to give a sense of what North American GPs are hearing. Another question arises; what about the many other types of therapy offered to a needy general public? In some cases patients that I see have been in therapy for many years and have only a vague notion of what adjective would characterize the approach used by their therapist. Here in Montreal, so many styles of therapy are available that it is truly confusing for all concerned. I suspect that very few are evidence-based and, given the need for sound evidence, this is a concern for many doctors. Perhaps some or even most of these therapies have been studied to some extent, but the resulting research publications were insufficiently scientific to reach the high-end literature that is used to establish guidelines.

I should mention that psychologists who have university affiliations frequently make CBT an important part of their psychotherapeutic armamentarium and let this be known to members of my profession, an important source of their referrals.

As a final note I should qualify my comments by pointing out that I’m fairly peripheral to the world of psychotherapy currently working in an emergency department, a palliative home care program and a community-based group practice. My early research interests other than St John’s wort include arrow injuries and childhood osteomyelitis in Papua New Guinea. On the other hand, all general practitioners/family physicians are called upon regularly to find appropriate resources for patients that we see and this, of course, includes psychotherapists.